Beyond School Inc

• POLICIES AND PROCEDURES

  A licensee must: (b) have an emergency plan that sets out procedures to prepare for, mitigate, respond to and recover from any emergency.

  Observation. Fire extinguisher has not been serviced annually.

  13020 - CCLR s.22(1)(b)
• POLICIES AND PROCEDURES

  A licensee must keep current records of each of the following: (c) a record respecting compliance with section 22 (2) (b) and (c) [emergency training and equipment].

  Observation. No record of an emergency drill being completed in the last year.

  13050 - CCLR s.56(1)(c)
• STAFFING

  A licensee must not employ a person in a community care facility unless the licensee or, in the case of a person who is not the manager, the manager has first met with the person and obtained all of the following: (a) a criminal record check for the person.

  Observation. Three of four employee files did not contain a criminal record check

  12040 - CCLR s.19(1)(a)

• EQUIPMENT AND FURNISHINGS

  A licensee must ensure that a healthy and safe environment is provided at all times while children are under the supervision of employees.

  Observation. A blind cord that is accessible to the children has come loose from its bracket posing a potential hazard to the children playing in the area.

  Corrective action. Ensure a safe environment is provided at all times.

  11010 - CCLR s.13(1)

No violations recorded at this inspection.

No violations recorded at this inspection.

• EQUIPMENT AND FURNISHINGS

  A licensee must ensure that a healthy and safe environment is provided at all times while children are under the supervision of employees.

  Observation. At the time of the inspection cleaning products were observed accessible to the children in care. This was corrected at the time of the inspection. Food items were observed being stored near the bathrooms posing a potential health hazard to children in the program. Some debris, dirt and exposed dry wall was additionally observed in the program posing an additional concern for children in the program. The LO reviewed these items in depth with the Licensee at the time of the inspection.

  Corrective action. Ensure a healthy and safe environment is provided at all times.

  11010 - CCLR s.13(1)
• HYGIENE AND COMMUNICABLE DISEASE

  A licensee must establish a program to instruct children in, and to practise the rules of, health and hygiene. Observation (CORRECTED DURING INSPECTION): One of the two washrooms that children were using at the time of the inspection did not have toilet paper available for use. The LO reviewed this item in depth with the Licensee during the inspection.

  Corrective action. Ensure health and hygiene practices are maintained at all times including have accessible toilet paper available.

  15030 - CCLR s.46(1)
• OR SUPERVISION

  Without limiting subsection (1), a licensee must ensure that (a) children attending a community care facility are divided into groups, with each group having no more children than that permitted in Schedule E.

  Observation. A child in care at the time of the inspection did not meet the age requirements for the program. The LO reviewed this requirement in depth with the Licensee at the time of the inspection.

  Corrective action. Ensure children attending the program meet the age requirements of the service type offered or submit a Temporary Placement Application to maintain compliance.

  14020 - CCLR s.34(2)(a)
• POLICIES AND PROCEDURES

  A licensee must: (b) have an emergency plan that sets out procedures to prepare for, mitigate, respond to and recover from any emergency.

  Observation. Emergency supplies were limited and not available for the program to use in the event of an emergency. The LO reviewed this requirement in depth with the Licensee at the time of the inspection.

  Corrective action. Ensure emergency supplies are available in order to recover from any emergency.

  13020 - CCLR s.22(1)(b)
• RECORDS AND REPORTING

  A licensee must keep, for each child, a record showing the following information: (c) daily attendance record, indicating for each day whether the child is absent or, if the child is present, the time of arrival and departure.

  Observation. The program attendance records were reviewed and several dates were not recorded on the records. LO reviewed this item in depth with the Licensee during the inspection.

  Corrective action. Ensure attendance records are accurate and include the dates going forward.

  19090 - CCLR s.57(2)(c)
• STAFFING

  A licensee must not employ a person in a community care facility unless the licensee or, in the case of a person who is not the manager, the manager has first met with the person and obtained all of the following: (a) a criminal record check for the person.

  Observation. Three staff files were reviewed and one staff working in the program at the time of the inspection did not have evidence of a CRC available. This is a repeat contravention.

  Corrective action. Ensure all staff files are complete including clear CRC results prior to working with children.

  12040 - CCLR s.19(1)(a)
• STAFFING

  A licensee must not employ a person in a community care facility unless the licensee or, in the case of a person who is not the manager, the manager has first met with the person and obtained all of the following: (c) a record of the person's work history.

  Observation. Three staff files were reviewed and a record of the person's work history was not obtained for one employee.

  Corrective action. Ensure staff files are complete including resumes prior to working with children.

  12060 - CCLR s.19(1)(c)
• STAFFING

  A licensee must not employ a person in a community care facility unless the licensee or, in the case of a person who is not the manager, the manager has first met with the person and obtained all of the following: (b) character references in respect of the person.

  Observation. Three staff files were reviewed and a minimum of two character references were not obtained for one employee.

  Corrective action. Ensure all staff files are complete including references prior to working with the children.

  12050 - CCLR s.19(1)(b)

No violations recorded at this inspection.

• OR SUPERVISION

  Without limiting subsection (1), a licensee must ensure that (b) the ratio of employees to children attending a community care facility is no less than that permitted in Schedule E. Observation (CORRECTED DURING INSPECTION): One staff was working in the program when the LO arrived at the facility. The staff did not have the necessary qualifications to be working in the facility. A second staff arrived during the inspection putting the facility into compliance. The LO reviewed the Regulations with the Manager which outlines the staff to child ratio that is permitted under Schedule E and explained the exemption application procedure.

  Corrective action. Ensure the correct staff to child ratio is maintained at all times as outlined in Schedule E.

  14030 - CCLR s.34(2)(b)
• RECORDS AND REPORTING

  A Licensee must keep (b) a current record of each person to whom the written agreement is delivered in accordance with that section [CCALA s.19]

  Observation. Five children's files were reviewed and none had evidence of repayment being delivered to the families. The LO reviewed this with the manager during the inspection. This is a repeat contravention.

  Corrective action. Ensure repayment agreement is recorded as delivered to each family.

  19052 - CCLR s.56.1(2)(b)
• RECORDS AND REPORTING

  A licensee must keep, for each child, a record showing the following information: (a) name, sex, date of birth, medical insurance plan number and immunization status.

  Observation. Five children's files were reviewed and two children did not have gender identified and one did not have immunization status identified. These are repeat contraventions.

  Corrective action. Ensure children's files are complete including gender identified and immunization status noted.

  19070 - CCLR s.57(2)(a)
• STAFFING

  A licensee must not employ a person in a community care facility unless the licensee or, in the case of a person who is not the manager, the manager has first met with the person and obtained all of the following: (b) character references in respect of the person.

  Observation. Two staff files were reviewed and once staff was missing during the inspection. All staff did not have references either available or confirmed at time of hire. LO reviewed this with the manager during the inspection. This is a repeat contravention.

  Corrective action. Ensure staff files are complete including reference checks completed prior to staff working in the program.

  12050 - CCLR s.19(1)(b)
• STAFFING

  A licensee must not employ a person in a community care facility unless the licensee or, in the case of a person who is not the manager, the manager has first met with the person and obtained all of the following: (d) copies of any diplomas, certificates or other evidence of the person's training and skills.

  Observation. Two staff files were reviewed and one staff file was missing during the inspection. One staff that did not have the file on site was not confirmed to have the correct training to work in the program. LO reviewed this with the manager during the inspection. This is a repeat contravention.

  Corrective action. Ensure staff files are complete including copies of diplomas, certificates or other evidence of the person;s training and skills.

  12070 - CCLR s.19(1)(d)
• STAFFING

  A licensee must not employ a person in a community care facility unless the licensee or, in the case of a person who is not the manager, the manager has first met with the person and obtained all of the following: (c) a record of the person's work history.

  Observation. One staff working in the program was missing a staff file which included a missing resume. LO reviewed this with the manager during the inspection. This is a repeat contravention.

  Corrective action. Ensure all staff files are complete and on-site including the resumes.

  12060 - CCLR s.19(1)(c)
• STAFFING

  A licensee must not employ a person in a community care facility unless the licensee or, in the case of a person who is not the manager, the manager has first met with the person and obtained all of the following: (f) evidence that the person has complied with the Province's immunization and tuberculosis control programs.

  Observation. Two staff files were reviewed and one staff file was missing during the inspection. Staff immunization status was missing from all of the files on site. LO reviewed this with the manager during the inspection.

  Corrective action. Ensure staff files are complete and on site in including immunization status.

  12090 - CCLR s.19(1)(f)
• STAFFING

  A licensee must not employ a person in a community care facility unless the licensee or, in the case of a person who is not the manager, the manager has first met with the person and obtained all of the following: (a) a criminal record check for the person.

  Observation. Two staff files were reviewed and one staff file was missing during the inspection. One staff working in the program did not have evidence of a criminal record check being completed.

  Corrective action. Ensure staff files are complete including CRC's prior to working with the children.

  12040 - CCLR s.19(1)(a)

• LICENSING

  A licensee must display in a prominent place in the community care facility both the licence, including any terms or conditions of the licence, and the name of the manager.

  Observation. The name of the manager is not posted near the CCFL in the facility. LO reviewed the intent of this requirement during the inspection.

  Corrective action. Ensure the name of the manager is posted near the Community Care Facility.

  10050 - CCLR s.11(1)
• POLICIES AND PROCEDURES

  If a person prepays part of the cost of services provided by a class of community care facilities designated by the Lieutenant Governor in Council, the licensee must, at the time of the prepayment, deliver to the person a written statement setting out the terms and conditions on which a refund of all or any of the prepayment will be made.

  Observation. Four children's files were reviewed and all four files did not indicate that parents have agreed to the prepayment agreement of the facility.

  Corrective action. Ensure a prepayment agreement is confirmed by parents.

  13080 - CCALA s.19
• RECORDS AND REPORTING

  A licensee must keep, for each child, a record showing the following information: (a) name, sex, date of birth, medical insurance plan number and immunization status.

  Observation. Four children's files were reviewed and all of the children's files did not indicate the gender or each child and was also missing immunization status. LO reviewed this requirement with the manager during the inspection.

  Corrective action. Ensure children's files are complete including gender and immunization status.

  19070 - CCLR s.57(2)(a)
• RECORDS AND REPORTING

  In respect of a record referred to in this Division, a licensee must (a) keep in a single place at the community care facility the records referred to in sections 56 to 58.

  Observation. One staff and the facility manager did not have staff files in the facility for review during the inspection. The LO reviewed with the manager the requirement for staff files to be kept current and in the facility at all times.

  Corrective action. Ensure staff files are complete and on site in the facility.

  19320 - CCLR s.59(a)